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Working with Pakistani service
users and their families
A practitioner’s guide
Shama Kanwar
Stuart Whomsley
HQ Elizabeth House, Fulbourn Hospital, Cambridge CB21 5EF.
T 01223 726789 F 01480 398501
www.cpft.nhs.uk
A member of Cambridge University Health Partners
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Acknowledgements
The authors would like to thank the following people for their assistance in producing this document:
Martin Liebenberg for his support in developing the document’s content and direction.
Dr Asif Zia for his contribution to the section on service users travelling to Pakistan.
Professor Zenobia Nadirshaw for reviewing a draft of this document and offering supportive comments.
Ahmed Ijaz Gilani for allowing us to use his article.
Janice Hartley for her advice on spirituality and mental health.
About the authors
Shama Kanwar has worked in community relations for over 14 years both at a strategic level advising Senior
Management on community and equality issues and at grassroots level with specific hard to reach BMER groups. Shama
has worked nationally as an independent facilitator in an initiative involving Police Officers and Muslim communities on
community cohesion and has been instrumental in setting up BME Staff Support networks in three organisations. Shama is
currently working as a Community Development Worker based in Peterborough working with Black Minority Ethnic and
Refugee communities, running community based projects that raise awareness of mental health and how to access
services. Shama also works at length with healthcare practitioners to engage with service users and their families to gain
an understanding of the role culture plays in the treatment and recovery of the individual.
Dr Stuart Whomsley is a clinical psychologist who works in an Assertive Outreach Team. In this role he has a long
established working relationship with a number of clients from the Pakistani community. He is involved in both
community development initiatives locally and good practice guidance for his profession nationally.
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References
Hilty, A. 2010. Western Psychology,
Eastern Cultures – Mismatch? Ezine
articles. Available at:
http://ezinearticles.com/?WesternPsychology,-Eastern-Cultures---Mismat
ch?&id=4130088.
[Accessed 21 November, 2010].
Gilani, A. I, Gilani, U.I, Kasi, P.M,
Khan, M.M, 2005. Psychiatric Health
Laws in Pakistan: From Lunacy to
Mental Health. PLOS medicine, Public
Library of Science. Available at
http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC1215469/.
[Accessed 29 November, 2010].
Introduction
Aap ki Awaz. Our Voice: The
Pakistani community’s views on mental
health and mental health services in
Birmingham, 2007. Published by
Rethink. Available at:
www.mentalhealthshop.org/products/
rethink_publications/our_voice.html.
[Accessed on 29 November, 2010].
Sajid, A. 2003. Death & Bereavement
in Islam. The Muslim Council for
Religious & Racial Harmony. Available
at:
www.mcb.org.uk/downloads/DeathBereavement.pdf.
[Accessed on 3 March 2011].
Culture is a shared, learned, symbolic system of values,
beliefs and attitudes that shapes and influences
perception and behaviour; an abstract mental ‘blueprint’
or ‘code’ and must be studied ‘indirectly’ by studying
behaviour, customs, material culture (artefacts, tools,
technology), language, etc.
Professor Kathleen Dahl
How do you capture ‘culture’ accurately
when it involves people’s visible and
invisible values and beliefs? Is it possible
to be completely impartial when writing
about your own cultural background as
I am doing? Do the experiences I’m
sharing in this work truly represent the
Pakistani culture? Furthermore, is it
‘fair’ or ‘ok’ to produce guidance on
the culture of a whole nation,
particularly one that is as rich and
diverse as the Pakistani culture?
These questions were considered when
deciding to produce this guidance and
weighed against the need to raise
awareness amongst practitioners of
how a service user’s culture may
impact on their engagement with
services and their subsequent recovery.
Pakistan is made up of different states
that vary significantly in language,
dress and ‘culture’, and it would take
a very detailed piece of work to fully
capture the customs of all the states
comprehensively. Considering the
background of the Pakistani
communities settled in Peterborough,
which reflects the cases used in this
work as reference, it seems more
realistic and reasonable to say that
this guidance has been produced on
the Pakistani culture but with ‘a
particular focus on the Mirpuri and
Punjabi communities’, which are the
majority Pakistani communities settled
in Peterborough.
It is almost impossible to measure the
external input people have during their
lives that shapes their sense of identity,
and to pinpoint the extent to which
someone lives their life according to
values passed down through culture
and the impact of their current
environment on them, if that is
1
18
different from when they were
growing up; as in the example of a
person coming to live in the UK as
an adult. As demonstrated by this
point, it is risky to make generalised
assumptions about culture, as cultural
values may be enforced by families
and communities but interpreted by
individuals. It is also important to note
that there may be cultural differences
across generations as there may be a
parent or grandparent that came to
live in the UK as an adult and their
children and grandchildren may be
born and brought up in the UK,
therefore their experiences would be
very different from each other. An
example is where taking the children
to the cinema may be seen as
appropriate by young parents of
Pakistani origin but may be frowned
upon by older members of the family.
For the reasons mentioned above, this
guidance should not be used as an
authority on all things Pakistani but as
a tool that can assist practitioners
when working with individuals and
their families in the context of having
positive regard to the person’s cultural
values and beliefs to build relationships
and aid recovery. The individual and
family should be given the opportunity
to express in their own words what
their cultural and religious1 identity
means to them as it will be unique for
each person.
The small sample of anonymised cases
used in this guidance resulted from
family work that I have undertaken in
my capacity as Community
Development Worker for BMER
communities. I was able to engage
more freely with families as my own
background is Punjabi and I am fluent
Although culture and religion are different things, people may talk about them as one or use the terms interchangeably.
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in Punjabi and the surrounding dialects
of the area and work with local
families where practitioners felt that
additional support with language and
culture would be beneficial for the
service users and their families. The
cases have been included to illustrate
the points being made rather than as a
measure of success, which varied from
the service user being discharged with
very positive results to very little
change in condition.
Shama Kanwa
Additional comments from the
second author
This has been a hugely rewarding
project to be involved in that is largely
the work of Shama. Working with
clients and families from the Pakistani
community has raised my curiosity
about their culture at both a personal
and professional level. Being culturally
blind, though not as bad as racism is
still not good, it is akin to neglect
compared to racism being abuse. The
importance of cultural awareness is
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two fold. First, it enables a better
understanding and formulation of the
person's psychological distress and
confusion together with its impact on
family and carers. Secondly, it increases
the likelihood that interventions
offered will be successful as they are
taking account of the cultural factors
for and against change.
In working with clients from the
Pakistani community, including people
born in England, it has struck me how
their understanding of mental illness
has greater components of the role
of the body and the spirit in these
conditions, but a lesser appreciation
of the mind, than when working with
clients of long standing English
heritage; a challenge for anyone
wanting to carry out standard
Cognitive Behavioural Therapy. This
has confirmed my bias to suggest
that a holistic approach that takes
account of mind, body and spirit is
usually the best.
Points to consider…
The first and most important
step is to ellicit, in an open and
non-judgmental way, the service
user (and if appropriate the
family’s) ideas, concerns and
expectations.
The second step is to recognise
that symptoms attributed to
possession by jinn are commonly
manifestations of a mental
disorder that will most likely
benefit from medical treatment.
The third step is to appreciate
that, although the patient and
relatives may obviously have
interpreted symptoms incorrectly,
beliefs that are strongly held (and
often socially convenient due to
perceived stigma) will be difficult
to alter at a time when anxieties
are running high.
Stuart Whomsley
‘pot’ out of which they would pay for
their wedding. Sometimes the money
may be used as a deposit for a house
which may be rented out to generate
more income for the extended family.
What should clinicians do when a
patient or the family or friends believe
that jinn are the cause of symptoms
or unusual behaviour?
In such cases where patients are
deemed to have a medical, psychiatric
or psychological disorder but are not
receptive to medical explanations,
patients can be encouraged to 'hedge
their bets’ by taking the prescribed
treatment while continuing with
spiritual therapy. This double strategy
may be the best hope of securing
adherence to prescribed treatments.
There may also be the additional very
important benefit that patients and
their families are willing to enter into
discussion about the other therapies
that are being tried. Whilst these
usually consist of repeated readings
of certain sacred texts, the concern
is that in desperation some families
may turn to exorcists who inflict
physical harm in an attempt to free
the individual from possession –
sometimes with catastrophic
consequences.
4
It is very important, therefore, to
establish channels of communications
with the patient, the family and any
spiritual practitioner whose help is
being sought.
Wider issues around accessing
services
According to a Rethink project focusing
on the Pakistani community’s view on
mental health and mental health
services in Birmingham, successive
studies have shown that people from
BME groups experience relatively
higher levels of mental illness than the
white British population. Some of this
may be attributed to socio economic
factors such as the experience of
racism, unemployment, homelessness,
social exclusion, poor physical health
and living in deprived areas.
Other findings of the research found
that stigma of mental illness needs to
be overcome to enable mental health
as an issue to be accepted and openly
talked about. People may be ignorant
or unaware of the facts of mental
illness and communities may not know
which services are available to them or
how to access these services once they
decide to recognise and ‘face the
problem’. It was also found that
cultural and language barriers can
hinder people from taking up services
and there is a ‘keep it to yourself’
approach adopted across the
community where mental health issues
are concerned.
As the service user will be thinking in
holistic terms, including faith, somatic
symptoms and perhaps mental illness
as understood by ‘Western’
practitioners, it is important for
practitioners to take a similar approach
and elicit an open response about how
the service user and/or their family
views the situation, even if only clinical
treatments are available. This will
enable the practitioner to learn about
any alternative treatments being
accessed such as spiritual healers.
Culture, faith, eastern, western –
ultimately these are labels we attach to
each other to help us make sense of
something that is new or different, the
real success when working with
people is if we can understand what
the labels mean to the individual and
how they interpret their own identity,
only then can we truly deliver a service
that focuses on and responds to the
needs of the whole person.
Conclusion
As discussed during the introduction,
the aim of this document is to
highlight important parts of the
Pakistani culture that will assist
practitioners in working with service
users and their families from Pakistani
backgrounds. We have used our
experiences of working with families
to highlight the issues raised, and the
subsequent input that was given to
support the delivery of a service that
was appropriate. In addition, some
cultural values have been explained
such as attitude towards relationships,
timings and diet that may also assist
practitioners to gain a better
understanding of some of the factors
that may be driving a particular
attitude or behaviour.
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spiritual healers will encourage families
to think about the possibility of a
mental illness where they feel that their
full criteria for possession is not met.
The role of the Islamic therapist in cases
of possession, who must have strong
faith in Allah, is to expel the jinn. This
is usually done in one of three ways –
remembrance of God and recitation of
the Qur'an (dhikr); blowing into the
person's mouth, cursing and
commanding the jinn to leave; and
seeking refuge with Allah by calling
upon Allah, remembering him, and
addressing his creatures (ruqyah). Some
faith healers strike the possessed
person, claiming that it is the jinn that
suffers the pain. The practice of striking
the person is deplored by Muslim
scholars as being far from the principles
of Islam. The general approach of
expelling evil spirits by convincing them
to leave is similar to the passage in the
New Testament (Luke 8:24) where Jesus
expels demons from a man who is
possessed. Though it is not often
spoken about publicly the Church of
England and the Catholic Church retain
Ministries of Deliverance for exorcisms.
Within mental health services over the
last twenty years there has been a
growing awareness of the spiritual
component to the mental illness with
the development of organisations such
as the Spiritual Crisis Network.
Although the individual or their family
may believe there to be a spiritual
component to a condition, this does
not always mean they believe the
individual is possessed by a jinn. A
belief in spells and evil eyes could mean
that a mental as well as physical illness
is viewed as having a spiritual element
to it other than possession therefore it
is important to engage with the
individual and their family to ascertain
their views on the condition and its
causes as this often proves instrumental
to recovery.
Through working with families that
believed there to be a spiritual
component to the service user’s mental
health, it has been important not limit
ourselves to medical treatment, and to
consider the wider options of
psychological therapies as well as
family work with those closest to the
service user.
The differences of cross cultural
understandings of mental health can
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be appreciated within the context of
models of how beliefs in Asia are
different from the ‘Western’ views
such as those illustrated in the table
below which has been developed
from an article by Hilty on cultural
differences:
Pakistani culture and communities
Islamic influence and culture
Asian
Western
Core values of ancient China such as
hierarchy, moral development,
achievement and social responsibility
as well as a dualistic model medical
system based on principles of balance
and harmony.
Pathology driven, overlaid by the
values of ancient Greece such as
individuation, self control and self
efficacy.
Cognition is abstract, paradoxical,
circular and indirect. The universe is
seen as a web of infinite connections
(holistic cognition).
Cognitive process is one of logic,
critical analysis and direct and rational
thought in which the universe is
conceptualised as the sum of its parts
(analytic cognition).
Socio-centric model of self which is
formed within the social context and
defined by it at any given moment. A
sense of self requires emotional
connectedness.
Ego-centric model of self where each
person’s sense of self is considered
autonomous and unique, individuated
and largely consistent regardless of
context.
Orientation is one of interactionism,
in which the presence of complex
causalities is assumed and the focus is
on relationships and reactions
between persons or the person and
the surrounding environment.
Orientation of the individual is one of
dispositionism, in which the internal
disposition of the individual is the
primary consideration.
Health is inclusive of all aspects –
physical, mental, emotional, spiritual
and social, conceived of as a state of
harmony and balance, illness being
termed as ‘patterns of disharmony’.
The model of Cartesian duality of
mind and body is adopted where the
two are separated, hence mental
illness being treated in many areas
independently of physical and spiritual
symptoms.
Religious beliefs and values have a
strong influence on society and its
culture. Even a person of longstanding English heritage who is an
atheist is likely still to hold beliefs and
attitudes that are Christian in origin
as a consequnce of growing up in a
society with a substantial Christian
faith history.
In this context it can be difficult to ask
a person to focus on themselves as an
individual during cognitive behavioural
and solution focused therapy , as they
may consider this a selfish act or may
simply not be accustomed to thinking
of themselves as an individual entity.
This echoes some African cultures
where one is seen to exist through
others in their family and community.
Often blood ties are seen as more
important than money therefore it
may not be unusual for a parent to
control their children’s finances until
they are married and sometimes even
after marriage. On the surface this
may be seen as a selfish act but
parents may put all the money they
collect from their children in a joint
Islam is the main religion practised
in Pakistan with around 97% of the
population being Muslim and the
remaining 3% made up of Christian,
Hindu and Sikh communities. Although
Shari’ah (Islamic law & jurisprudence) is
not strictly practised in Pakistan, Islam
governs people’s personal, political,
economic and legal lives on a daily
basis making religion an important
factor to consider when working with
Pakistani families, as the lines between
faith and culture are often blurred.
Pakistan and Azad Kashmir
Pakistani culture is made up of a
mosaic of Islamic traditions and is
influenced by Hindu culture, which is
evident in the way weddings are
celebrated and events such as ‘Basant’
(spring festival). Pakistani Muslim
families or individuals within them can
be either culturally or Islamically driven
and still identify themselves as
Pakistani and Muslim. Variations can
include naming traditions where a
family driven by culture may choose an
Urdu name such as Shabnam (morning
dew) for a female child and Sahil
(seashore) for a male child. A family
with a more Islamic outlook may give
their child an Islamic name such as
Maryam (Mary) for a female child or
Muhammed for a male child although
cultural and religious names may be
given together. Social areas such as
the level of free mixing may also differ
depending on whether a family is
more cultural or religious as well as
the level of access to media in the
home such as Hindi film and television.
As Mirpur has no airport, passengers
from the UK will often use Pakistan’s
Islamabad airport from which Mirpur
is a 2 to 3 hour journey.
Unlike Christian families where the
gap between practising and non
practitising Christians is much wider,
the majority of Muslim Pakistani
families identify quite strongly with
their faith and will practice it at some
level. As a minimum, families may
16
have a pork and alcohol free diet and
pray or read the Holy Qur’an
occasionally whereas a practising
family will adhere to the five daily
prayers, observe hijaab (Islamic dress)
and may not allow free mixing. Adding
to this an influence of the Hindu and
British culture in Pakistani families
highlights the level of diversity that
makes up ‘Pakistanis’ and people from
a Pakistani background.
Azad Kashmir is a self governing state
to the North-East of Pakistan which
is administered by the Pakistani
Government. The largest City in Azad
Kashmir is Mirpur which is
neighboured by the province of Punjab
in Pakistan. The largest Pakistani
community in Peterborough is the
Mirpuri community coming from
Mirpur and the surrounding areas,
followed by the Punjabi community.
Pakistani dress
When we first meet a person we will
be making rapid judgements of who
they are and where they fit in to our
understanding of society. In this rapid
account the clothing a person is
wearing can play an important role.
The clothes that we wear can be a
strong marker of personal identity,
age, class and culture.
Points to consider…
Where possible, allow the service
user to describe in their own
words how they view their
cultural identity.
This is important considering the
cultural diversity of Pakistani
families depending on how
‘traditional’ or ‘Western’ they are,
how much they are influenced by
practices deriving from the Hindu
culture and how closely they
practice the Islamic faith.
Gaining this information will help
you to recognise the level of
importance the individual’s
cultural heritage holds for them
and how this may influence their
treatment and recovery.
Point to consider…
Some people from Azad Kashmir
may identify themselves as
‘Pakistani’ on ethnic monitoring
forms but will consider
themselves as ‘Kashmiri’ or from
‘Azad Kashmir’ in everyday
conversation.
The national dress of Pakistan is
shalwar kameez which is a long top
with loose, baggy trousers. Men may
also wear a skullcap and women will
usually wear a large scarf with their
shalwar kameez.
In the UK, men often adapt to the
‘Western’ style of dress unless they
come to the UK when they are older,
where the preference is to wear
shalwar kameez. Women will wear
a variety of dress ranging from the
shalwar kameez worn in the traditional
way or ‘anglicised’ by wearing trousers
with a long top, to totally ‘Western’
dress. In recent years there has been an
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increase in women choosing to wear
the ‘hijaab’ which is an opaque piece
of material wrapped around the head
and held secure with a pin. This can be
worn with shalwar kameez, ‘Western’
clothes or then with a jilbaab which is
a long coat like dress that reaches
down to the ankles. Pakistani dress is
linked to modesty which is a value of
Islam and is usually maintained by
people of Pakistani origin however
they may choose to dress.
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Parveen
Parveen is in her teenage years and has been diagnosed with anorexia.
The immediate and extended family’s diet consists mainly of Pakistani food,
particularly those that are rich in spices, flavours and cholesterol and the
family equate being ‘big’ with being healthy and well. The women of the
house insist on cooking and serving food to Staff whenever they visit, this
being seen as a sign of hospitality and graciousness. This includes being
served fried food with fizzy drinks early in the morning and three course
meals when visiting to support Parveen to eat during lunch visits. The
family often insist that everything on the table be sampled including large
quantities of fried food.
Gold jewellery
Pakistani communities will have
differing views about men wearing
gold jewellery as some men may wear
a gold ring, bracelet or chain and
others believe it is not permitted in
Islam. Women however are
encouraged to possess and wear gold
jewellery as a sign of wealth and good
status. It is traditional for women to
wear gold bangles and other jewellery
on a daily basis and daughters will be
given gold jewellery by direct family
members upon their marriage which
stems from the notion of giving
something that can be used during
times of hardship. Often gold jewellery
is passed down to daughters and
daughters-in-law.
Diet and food
One of the most common markers of
cultural identity is the individual cuisine
that a culture has developed. This is
one of the most accessible ways that
a person from one culture can
experience and value that of another.
Pakistani food fits within the wider
culinary framework of Indian food
and as such is something that has
familiarity and value in the UK.
Food is an industry that excels in
Pakistan even when the economy is
down, perhaps because this is one
of the few areas where people from
lower socio economic groups can
demonstrate control and discretion,
as affording a car or going on a lavish
holiday would not be achievable.
6
Parveen’s family were encouraged by her dietician in supporting her to
stick to a food plan that would slowly introduce eating back into her daily
routine again. The family continued to offer Parveen other foods at the
dinner table despite being explained that this would hinder her progress.
The family have different ideas about the ‘truth’ regarding diet that was
not shared with Parveen’s clinicians; and seemed to attempt to introduce
extra foods to Parveen whenever the opportunity presented itself. This
hindered Parveen’s progress and she often spoke about an atmosphere in
the family home in which they did not speak openly about problems and
issues and how difficult it was for her to share things that were on her
mind with her mother or other family members. After months of support,
Parveen’s family are now taking part in family therapy with a view to
admitting her into hospital if her weight does not improve.
Pakistani food is rich in flavour, spices
and high in cholestrol with sweet
desserts containing a high sugar
content. The use of meat and chicken
is very common at mealtimes and it
would be considered offensive to
serve a completely vegetarian meal at
a dinner party or to guests, although
a vegetarian accompaniment would
be acceptable.
Culturally, food is linked to hospitality,
seen as a sign of good living and the
sharing of food as an act of kindness.
It is common to serve food at festivals
and gatherings and is given away to
the poor during times of happiness
such as a wedding or the birth of a
child or grandchild.
Guests will be encouraged to share a
meal and may have food put on their
plate and offered seconds or thirds
despite the recipient’s protest, as
illustrated in Parveen’s case. Babies and
children are seen as healthy if they are
on the upper end of the normal
weight range and may often receive
comments about their health
depending on how much weight they
have gained or lost, which is in
contrast to the ‘Western’ culture
where it may seem inapproriate to
comment on a baby or child’s weight.
Mental health and Pakistani communities
Spirituality and understanding of mental illness in Pakistani communities
Excerpt from ‘Psychiatric Health Laws in
Pakistan: From Lunacy to Mental Health
By Ahmed Ijaz Gilani
There are many players and factors involved in the access, provision,
delivery, functioning, and uptake of mental health services in Pakistan.
Awareness about mental illness is still poor in Pakistan. Such illness is
generally attributed to supernatural causes—it is considered to be a curse,
a spell, or a test from God.
Those who experience mental illness often turn first to religious healers,
rather than mental health professionals, since patients and their families
tend to have great faith in these healers. Religious healers use verses from
the Qur’an to treat patients. Next, patients turn to traditional and
alternative healers, who are also popular in Pakistani society.
Help from the mainstream health-care system is usually sought late in the
course of the illness; however, the referral system is inefficient and,
particularly in the case of individuals who are mentally ill, patients are usually
taken by their families directly to tertiary or specialist hospitals, rather than to
primary-care practitioners. It is, however, important to note that many
mental illnesses can be treated and managed by primary-care practitioners.
The private sector also plays a major role in providing psychiatric care. For
those who can afford it, private psychiatric care is an option frequently used.
[Excerpt from section on Mental Health Infrastructure].
In view of the above account of
mental health services in Pakistan,
understanding of mental illness in
Pakistani communities is significantly
different from the models commonly
used in the UK. As well as mental
illness being considered in a holistic
context including environment and
physical health, it is also understood
in the context of spirituality.
Belief in supernatural forces is
prevalent in Pakistan. Jinn (anglicised
to genies), evil eye and spells are part
of daily life in Pakistan and spiritual
healers can be found in most markets
and street corners.
According to Islamic belief, jinn are real
creatures that form a world other than
that of mankind. There is little detailed
description of jinn in the Qur'anic and
Prophetic literature. The term ‘jinn’ is
derived from Arabic ijtinan, which
means 'to be concealed from sight'.
Although they reside in what are in
essence parallel worlds, humans and
jinn are believed by Muslims, to have
some ability to influence each other
towards both positive and negative
ends. Satan (who is within the Islamic
tradition a jinn and not an angel, and
hence has the choice to disobey) is the
most infamous of the jinn and is
primarily concerned with enticing
humanity to forget its divine origin.
According to Islamic writings, jinn live
alongside other creatures but form a
world other than that of mankind.
Though they see us they cannot be
seen. Characteristics they share with
human beings are intellect and
freedom to choose between right and
wrong and between good and bad,
but according to the Qur'an their
origin is different from that of man.
According to Islamic scholars, a person
unable to think or speak from their
own will, experiencing seizures and
speaking in an incomprehensible
language may be possessed by jinn;
however, more often than not a
physical cause can be found for the
unexpected behaviour and many
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NHS Working with Pakistani Service Users 2011 PP.qxd:A4
Pakistan. Clozapine is not a commonly
prescribed medication in Pakistan and
the monitoring procedure differs to
that in the UK. The user will need to
obtain for themselves a blood test at a
hospital or private laboratory for a full
blood count. They or a family member
or carer then phone the drug
company's monitoring service and
inform them of the results. The drug
company will then deliver to where
they are staying and will ask to see the
results printout in confirmation before
handing over the medication.
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Points to consider…
Not all people with a Pakistani background will have a good practical
knowledge of Urdu, therefore it is important to ascertain the particular
Pakistani language or dialect the service user speaks at home.
Mirpuri and Punjabi are the most popular Pakistani languages in
Peterborough. Both languages use the written form of Urdu as there is no
written form of Mirpuri and Pakistani Punjabi speakers will not be able to
read or write the written form of Punjabi.
Most interpreters that speak a Pakistani language will also speak Urdu.
Service users may wish to have a same sex interpreter.
Pakistani languages & interpreting
The term ‘Pakistani’ includes a mosaic
of different cultures. The national
language is Urdu and is spoken in the
public sector as well as English. Many
other languages are spoken in the
different regions of Pakistan such as
Punjabi, Siraiki, Sindhi, Pashtu, Balochi,
Hindko and Gujurati and the diversity
in languages is often reflected in
differences in culture, diet and
traditions. It would be true to say that
a significant number of people living in
more isolated or rural areas of Pakistan
may not speak Urdu.
The majority of Pakistani families settled
in Peterborough speak Mirpuri or
Punjabi. This is an important point to
keep in mind as not all those that speak
Where the service user is unable to read or write, they can be involved in
using pictures and photos from South Asian media to tell their story.
Examples of alternative media include the Asian Bridal magazine, MAG
the weekly and the Jung, Nation & Watan newspapers as well as
mainstream media.
Mirpuri or Punjabi will be comfortable
with having an Urdu interpreter even
though Urdu is the official language of
Pakistan. It may be more appropriate to
request an interpreter that specifically
speaks Mirpuri or Punjabi, as many
interpreters registered to speak
languages from Pakistan will almost
always have a good knowledge of
Urdu. Mirpuri and Pakistani Punjabi
speakers will use the written form of
Urdu if they need to write something
down in their language.
Weight gain or loss in adults is viewed
in a similar way.
More full bodied actors and actresses
are common in the Pakistani film
industry and weight loss, even when
done in a healthy way is sometimes
viewed as a sign that something is
wrong physically in the form of an
illness or due to mental distress such
as problems in the family; although
younger people may identify more
with the ‘Western’ ideals regarding
weight and may therefore be more
aware and conscious of gaining
weight. In Parveen’s case the family
were concerned that the extended
family or community members would
think there was something wrong in
the family and that was the reason for
Parveen’s weight loss, and her lack of
eating was a cause for tension during
festivals such as Eid.
In many Asian cultures including
Pakistani cultures, foods are
considered in terms of ‘hot’ and ‘cold’.
This is not concerned with the
temperature at which the food is
served but rather the ‘effect’ on the
body, which can be harmful if food
combinations are not balanced. For
example, almond nuts are ‘hot’ when
eaten as a nut but ‘cold’ if soaked
overnight in water providing the outer
layer is removed. Mangoes are
considered ‘hot’ and should be
consumed with yoghurt milk (lassi) as
this has a cooling effect on the body
therefore neutralising the heat in the
mangoes. Although not so prevalent
in Pakistani communities, Hindu
communities associate certain foods
with mental and emotional states such
as meat with aggressive behaviour, as
well as recognising the physical ‘hot’
and ‘cold’ effects on the body.
The sense of time
‘I remember visiting my
great grandmother’s house
in Pakistan as a child and
not having a clock in the
house, even if there was it
would have been no good
to her as she couldn’t tell
the time.’
14
How time is understood and valued
differs between cultures. This is an
area that industrial businesses have
had to pay close attention to in order
to function efficiently in different
countries. Some cultures value
punctuality, meticulous planning and
stay committed to them. Countries
that typify this approach, technically
known as ‘monochronic’ are the USA
and Germany . In contrast there are
polychronic cultures which include
Pakistan. In these countries multiple
activities occur at once, there is greater
flexibility around time with the focus
on the relationship being more
important than promptness or the job
in hand.
Timing is very relaxed in Pakistan,
particularly in the more rural areas
away from office based companies.
Social visits to family and friends are
made unannounced as many
households have an ‘open door’ policy
where the door is left unlocked during
the day for people to visit. The main
structure to the day is around the five
daily prayers and timings may be given
around these, for example, ‘I’ll see
you after dhuhr’ or ‘make sure its
before maghrib’.
Points to consider…
Psycho-education is key when
working with Pakistani families
around eating disorders to help
them to understand the
condition and support the
recovery of the individual.
Talking therapies around eating
disorders often involve individual
and family work. Families may not
be comfortable with talking
about the family and its dynamics
as this would normally be done
on a one to one basis or with a
small trusted same sex group.
Families will most likely feel under
pressure from the wider
community and may hide the
problem rather than talk about
it openly.
Weddings and such functions are very
relaxed affairs with no set start time
and guests arriving and being served
at various times. Although the
structure of the day is relaxed, there
are customs around visiting a family
where there has been a birth of a
child or a death as soon as possible
and offence could be taken if a family
member or friend were not to visit on
such an occasion. Similar rules apply
to inviting a newly married couple
around for a meal after their wedding,
as the first few months are usually
taken up by being invited by family
and friends to meals where delicacies
are served and gifts given to the new
bride and groom.
Accommodation
It is customary in Pakistan to buy and
acquire land so that property can be
built and extended as the family size
grows. Often, a house will start off
with two or three rooms and will then
be extended as per the family’s needs
which is particularly the case in more
rural areas. In more suburban areas
where it is not possible to extend due
7
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
to lack of space, a property adjacent to
the family home or nearby will be
purchased to keep extended family as
close as possible. In Pakistan it is still
not widely accepted for a couple to
move out of the husband’s family home
and in such cases this will only happen
where there is a family rift or
diasgreement. The young couple is
almost always seen as being responsible
for the separation, for not showing
tolerance and patience to their elders.
In the UK, many families follow a
similar model. Families in the Central
Ward of Peterborough have preferred
to extend small properties to allow for
growth over moving into larger homes
which would mean moving out of the
area. Extended families living in the
same home or nearby are respected by
other community members as they are
seen to be practising true Pakistani
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Page 8
values. For this reason, families often
resist the urge to separate after
marriage as they are aware of the
stigma associated with moving away.
Where couples do separate after
marriage, significant time is often
spent at each other’s houses to show
that the family is still a strong unit. This
custom usually only applies to sons as
daughters can be married outside the
area but would have the same
expectations placed on them in their
husband’s home. This has implications
for when clinicans may consider that it
would be benefical for the service
user’s mental health to move to
supported accommodation either to
help their recovery or to manage with
risk issues. Such a move away from the
family home could produce an
additional stigma in addition to that
of mental health, making it an even
harder move to achieve.
Points to consider…
An appointment with a clinician
may not be kept if a family
member or friend arrives at the
house unannounced as it would
be considered rude to ask the
person to return at a different
time.
Families with very traditional
values only plan their calendar for
a number of days, therefore it is
not unusual for an appointment
sent weeks in advance to be
forgotten or to be confused with
a different date. The service user
is not being awkward, they simply
may not be used to this,
particularly if they do not have
school age children to provide
structure to their day or are new
arrivals to the UK.
If embarking on an extended
piece of work with a service user
and/or their family, it may be
useful to emphasise the
importance of keeping
appointments, attending on time
and notifying someone if they
cannot attend.
Pakistani communities in Peterborough
Localities
Maliha
The majority of Pakistani families in
Peterborough are from the Mirpur area
of Azad Kashmir that have been
settled in the UK for over 50 years.
In line with national trends, there are
a significant number of Punjabi
Pakistanis followed by people from
other areas such as Sindh. The
Pakistani community is concentrated
around the Central Ward area
expanding out to surrounding areas
such as West Town, Dogsthorpe, New
England and more recently Netherton,
with a few families living in other areas
across Peterborough.
Travel to and from Pakistan
It is customary for people to keep close
ties with family in Pakistan as well as
family in and around the UK and
annual holidays to Pakistan for periods
of four weeks or more are common to
make the cost of travel worth while.
Popular reasons for travelling to
Pakistan apart from visiting family are
to familiarise children with their culture,
marriage and to promote the traditional
customs and values when living in the
UK. Visits to Pakistan are usually a
highlight for people of Pakistani origin
as they may not have regular holidays
as understood in the UK. Families
spend time shopping for their family in
Pakistan and family members in the UK
tend to visit to say goodbye, making it
a time of happiness and anticipation
and this was the case for Maliha who
benefited immensely from seeing her
family in Pakistan for the first time
without her abusive husband.
Clients from the British Pakistani
community frequently travel to
Pakistan to meet their relatives and
for holidays. These trips to Pakistan
can last for a number of months and
therefore raise the issue of treatment
whilst there. When in Pakistan some
people visit shrines, faith healers and
also see a psychiatrist.
It is prudent to advise clients that whilst
they are in Pakistan they continue with
the medication they are taking and not
change it unless advised to do so by the
UK treating team. This is to prevent
clients from suffering relapse or return
8
Maliha had been diagnosed with depression and had taken medication for
her condition for many years. She came to the attention of secondary care
services upon the birth of her child and separation from her husband which
followed shortly after. Maliha has other children and had endured domestic
and financial abuse from her husband for many years. Although she had
been visiting doctors for a long time, Maliha’s husband had been allowed to
interpret for her and she was never seen alone to have the opportunity to
share her ordeal with anyone. Maliha’s eldest daughter was still under 16 but
not in any form of education or training and took on most of the household
chores and looking after her younger brothers and sisters.
I found Maliha very low, isolated and scared of telling anyone about her
problems, spending most of her time feeling very tired and down. Maliha
said she found it difficult to undertake any household chores as her body
ached afterwards. I interpreted some basic information about depression to
her in Punjabi and worked in a pictorial way to help her understand her
depression and how the mental state was linked to her physical state
resulting in the pains and aches. Maliha improved over the coming weeks as
she was able to talk about the issues around her marriage in a cultural
context. During a review, we found a number of things that had been
misinterpreted such as Maliha hearing water when she had actually been
describing her depression and how she felt that she was drowning in her
sadness. Maliha responded very well to the basic techniques around
managing her depression and within a few months was able to take over
many of the household chores from her daughter and went to visit her
family in Pakistan and was subsequently discharged.
of their illness which would spoil the
time they are in Pakistan. It is worth
noting that there are differences in
practices, medications available and
doses of drugs. It also might not be
possible to continue the medication
started in Pakistan.
Pakistan also has a high rate of
Hepatitis and other water and blood
borne infections. Caution is required
with those medications that are
administered by injection e.g. Depot.
Service users and their families should
be advised to buy needles from
reputable sources and to dispose of
them safely.
For clients who are on medication that
requires blood tests it is important to
consider the following: The blood tests
may not always be reliable, depending
on the type of health care facility in
which they are taken. There are issues
with used needles being repackaged,
so appropriate care should be taken
in sourcing clean ones. People taking
Clozapine will need to register with
the Clozapine monitoring service in
13
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
Often titles significant in the
community or religious sense may
be used such as ‘Haji’ if someone
has completed the Hajj pilgrimage
or ‘Choudhary’ if someone is a
landowner or in a position of power
in a village setting system; although
Choudhary has more recently been
used as a surname.
Names
Names and their meanings are very
significant in the Pakistani culture. First
names are considered to influence the
individual’s personality and life and
parents or older family members may
rename a child if they develop ongoing
ill health or other problems as the
name may be seen as ‘heavy’ for the
individual; ‘heavy’ in this context
would be if the definition of the name
had a negative connotation such as
‘sacrificer’ or ‘oppressed’ and also if
the name was that of a historical
figure that had lived a difficult or
trying life. Families that are more
culturally driven would usually
subscribe to this notion.
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Page 12
Points to consider…
Considering the naming
combinations, it is not unusual
for members of the same family
to have different surnames, for
example a father may be called
Mohammed Atif Khan and his
daughter may be called Samina
Bi. Samina would not inherit her
husband’s surname upon
marriage.
Pakistani families and communities
The concept of family
In Pakistani communities the concept
of ‘family’ is the basis of social
structure and individual identity
encompassing more than the nuclear
family and immediate blood relatives.
Family is a term that is used to
describe distant relatives as well as
those acquired through marriage and
includes people from the same
baradari (tribe), friends and
neighbours. Some people may also
refer to people from the same village
or general area in Pakistan as part of
their family. Amongst Pakistani
families, there is a greater sense that
a person does not only represent
themselves but is part of the ‘family’,
therefore successes and failure, praise
and shame can be shared by the family
in the wider sense.
Marriage
Who and how we choose to form
couple relationships with, marry and
have children with has a strong
cultural component. The relative
weighting of determinants such as
practicality or romantic love differs
between cultures, within them over
time and varies between individuals
within that culture.
Traditionally within Pakistani cultures,
marriage is seen not only as the union
of two individuals but is seen as an
alliance between families, or often a
reconfirmation of alliances within the
family in the broader sense outlined
above. Within traditional families,
suitable partners that meet the family’s
expectations around family, tribe,
wealth or education, are suggested to
the individual by a respected member
of the family to seek their opinion on
the match. This process can work in
the reverse order where the individual
(more often the male than female)
suggests a partner to their parents or
other respected member of the family.
Providing the person being suggested
meets with the family’s expectations
and neither of them is already
betrothed, the marriage is usually
arranged in the traditional way.
Arranged marriages often have very
positive outcomes and are not to be
confused with a forced marriage.
12
Sometimes individuals are forced into
a marriage where one or both partners
do not consent. In this case the
individual’s choice is overlooked
because of the perceived benefits of
the match to the wider family such as
reinforcing family ties, culture or for
economic reasons. Such arrangements
can be the cause of much distress
and there are services available to
help people suffering in these
circumstances.
The process of choosing a partner or
having a ‘love’ marriage is becoming
increasingly popular in the less
traditional families living in the larger
cities where dating or marrying
someone outside the ‘family’ is now
also becoming acceptable.
Marriage and mental illness
Where a young family member has a
diagnosis of mental illness a marriage
may be sought as a way of solving the
problem and/or share the burden of
care. This could also be considered
as a social inclusion approach when
mental illness is not seen as an
exclusion from normal life roles such
as being a partner or parent.
Points to consider…
It is not unusual for extended
family members to have input
into matters relating to the
service user.
Sometimes an older child is used
to interpret and talk about
problems. This is seen by the
family as acceptable because an
older child is encouraged to take
on adult duties from a young
age; however, it is important for
practitioners to consider the
child’s wellbeing and use an
interpreter for anything but the
most basic interpreting.
Immediate family members of
the service user can sometimes
feel pressurised by family
members in a position of power
or authority such as a parent,
uncle, aunt or in laws of the
service user. These family
members could live nearby,
elsewhere in the UK or abroad.
Parents may take the decision to find
a partner in Pakistan where a poorer
relative would agree to marry their son
or daughter to enhance the family’s
economic status, particularly with a
son where it is felt that he would be
able to earn money in the UK and
support the family back home. The
family in Pakistan would then rely on
their son once he was in the UK to
provide financial support for their
sibling’s weddings and to provide
electrical goods such as laptops and
televisions in addition to a monthly
allowance. This has been a recurring
theme with families I have worked
with and has been the case for Sadia
and Tariq (see case study page 10).
This arrangement may lead to further
complications once the spouse comes
to the UK and the severity of the illness
is realised by the partner from Pakistan.
Where the woman arrives from
Pakistan, she often has no way
of sharing her experiences of living in
a country where she does not
9
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
understand the language or customs
with a husband who is unwell and
living with extended family and looking
after the household. This may lead the
woman herself to experience mental
health problems such as depression
and anxiety and may only come to the
attention of services during a
pregnancy and childbirth where mental
distress may be picked up in the form
of post natal depression.
In the case of the male partner coming
to the UK, there may be much family
tension between the male and his
wife’s family as he may feel tricked
and betrayed once he realises the
extent to which his wife may be ill.
Due to the perceived stigma and
shame of a failed marriage, the wife’s
family may take over the responsibility
of their daughter’s household including
cooking, care of children and offer
financial assistance to ensure the
marriage is not dissolved once the
husband receives permission to stay
in the UK permanently. This was very
much the case in Sadia’s family as her
mother had pushed for Sadia to be
married to a maternal cousin and felt
it would be further shame for her in
particular if her daughter was divorced.
The conclusions to be drawn from this
are obvious: where an arranged
marriage is to occur between a person
with a diagnosed mental illness from
the UK and a person from Pakistan,
the potential partner from Pakistan
needs to be made fully aware of the
circumstances so that they can make
an informed choice. This is not only
the most ethical position, meaning the
marriage remains arranged rather than
forced, but also avoids much potential
heartache in the future.
Death and bereavement
Death and bereavement are times
when a family is most likely to follow
Islamic teachings whether they are
practicing or not in everyday life;
therefore Islamic practice will be
referred to in this section with any
10
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Sadia
Sadia is a young woman of Pakistani origin who has managed an obsessive
compulsive disorder since her teenage years. Sadia’s family took her to
Pakistan and married her to her cousin Tariq. This has exacerbated Sadia’s
illness to the point that she hasn’t been able to manage her rituals and the
demands of her married life since Tariq came to live with her and her family
in the UK. Tariq is not supportive due to a lack of understanding around
Sadia’s OCD, believing that she is making everything up. Sadia’s family are
fearful of the shame that would come to the family if Tariq left and at times
while working with the family it was felt that Tariq took advantage of this.
Sadia’s family affords Tariq’s living expenses and on one occasion Tariq left
home after an argument involving extended family members on both sides
of the family, insisting on Sadia apologising to his family before returning
home. Sadia described the incident and talked about how degraded she felt
apologising to protect the family’s honour even though she didn’t feel that
she had been in the wrong. Sadia’s Mother performs many of Sadia’s rituals
for her such as doing household chores in the way Sadia feels they should be
done and doing them repeatedly to ‘keep the peace’ in the house.
variations in Pakistani culture being
made explicit. Muslims believe that
death is divinely willed and when it
arrives it should be readily accepted.
With this in mind, there is rarely any
questioning by the bereaved as to
why they have lost their loved one;
therefore it would not be culturally
appropriate to voice such questions
during the mourning period or
afterwards which could cause a barrier
during talking therapies if the topic of
discussion is one’s feelings about
losing someone.
Muslims are always buried and never
cremated and the dying person is
encouraged to recite and declare his
or her faith. Upon death the body is
treated gently and with respect, being
washed or bathed, scented, and
covered with a clean cloth for burial.
It is very important that the body is
released from the hospital, with all the
necessary papers as unnecessary
delays in the burial would cause
distress to the family. Muslims are
directed to conduct the burial as soon
as possible after death. These Islamic
values are strong in Pakistani families
and it is common in Pakistan to bury
the person on the day of their death;
therefore families accustomed to this
practice may find it particularly
distressing in the event of a delay.
While Islamic traditions recommend a
person to be buried in the area they
die, it is usual for a Pakistani person
living in the UK or their family to have
their body flown to Pakistan as their
final resting place. One of the main
reasons cited for this is that Muslims
are required to be buried wrapped in a
large cloth without the wooden coffin
which is not permitted in the UK. It may
also be that people want to be buried
in Pakistan to be buried with other
deceased relatives. The decision to fly
a body to Pakistan for burial can place
undue financial pressure on the family
as it is an expensive process.
When there has been a death in a
household, it is common practice for
friends and relatives to visit from all
over the UK, the family being
supported by local relatives with food
and providing overnight
accommodation where necessary.
Islamic practice recommends mourning
for a period of three days for any friend
or relative, however cultural practices
vary and in some cultures a period of
mourning can be up to forty days. In
the case of a wife losing her husband
the period of mourning lasts for four
months and ten days. This period of
time is referred to as ‘Iddah’ or ‘period
of waiting’ during which the wife is
encouraged to perform only those
duties that are absolutely necessary
and is not allowed to remarry until her
‘iddah’ period is over. There are a
number of reasons for this, amongst
those are giving the wife time to grieve
without the demands of everyday life
and she is not allowed to marry to
prevent confusion of the child’s father
were she to fall pregnant if she
remarried. During the mourning period
weeping or crying quietly is permissible
in Islam, but crying loudly or wailing is
discouraged; however, in some
Pakistani cultures wailing still takes
place, particularly amongst women.
married and have children of their
own, their status changes and they are
thought of as mature. This is not linked
to age as status in this context would
not change until marriage, regardless
of age.
Another phase is when one’s children
are married and they become
grandparents. In some cases this could
be as early as the late thirties when
the individual is seen to have fulfilled
their responsibilities and is elevated
in status to be considered an older
or more respected person. The final
phase is when people become more
religious and spend more time in
worship and resting while the
children and grandchildren look after
their needs.
Points to consider…
As Muslims are taught to accept
the passing of a loved one and
not question it, people may find
it difficult to open up during
talking therapies as they may feel
guilt over their feelings.
Families may travel to Pakistan at
short notice if a relative passes
away there. As these visit can be
arranged in a matter of hours,
families may not be able to
contact practitioners if a service
user is also travelling regarding
medication or other issues
relating to their care whilst away.
Older people
Pakistan is a hierarchical society and
one of the commonalities that runs
across all Pakistani cultures is the
respect of older people because of
their age and position. Older people
are seen as being experienced and wise
and in social settings may be served
first and have drinks poured for them.
It is widely unaccepted for older people
to go into a residential care home as it
is seen as an honour to look after older
members by the young although
homecare is usually accepted.
In decision making, the most senior
person by age or status (this could
include being head of the house or
in a job viewed as respectable) is
expected to make decisions that are
in the best interest of the group.
Points to consider…
Immediate family members may
try to keep the service user’s
illness a secret from other family
members or in laws to prevent
stigma and impact in the
relationship if the spouse is still
in Pakistan. This may add more
pressure on the family and
service user to ‘recover’ so they
can get pregnant in the case of a
female or get a job in the case of
a male to show wider networks
that everything is ok.
Family pressures can exacerbate
a person’s illness more so than in
a person that is not from a
Pakistani background.
If a close family member passes away
in Pakistan, their family in the UK may
wish to go to Pakistan at short notice.
If it is deemed that there would not
be suitable care for a service user
while caregivers are away, the decision
may be made to take them along
without consulting practitioners as
priority would be given to being
united with family in Pakistan during
the time of loss.
Age
In the Pakistani culture, ‘age’ is not just
physical but is also linked to phases in
life. For example people are considered
to be ‘young’ before marriage and
their opinion may not be sought in
family matters; however, once they are
Some older Pakistani people settled
in the UK may choose to spend the
winter months in Pakistan as it is
believed that spending time in a
warm country promotes health
and wellbeing.
Titles
Similar to many other cultures, an
older person will not be referred to
by name as a mark of respect. Older
people will be referred to as uncle,
auntie or as grandparents (in their
respective language) if they are older.
The word ‘ji’ is commonly added to
titles as an added mark of respect,
for example ‘chachaji’ would be a
paternal Uncle (chacha) with ‘ji
added for respect.
Points to consider…
As older family members are so
well supported and cared for
within the family network, a
deterioration in physical health
will be picked up quickly.
Concerns around mental illness
may not be picked up if the
awareness is not there as the
older person will be
accompanied to appointments
and may not access situations
where mental health problems
could come to light such as older
people’s groups.
11
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
understand the language or customs
with a husband who is unwell and
living with extended family and looking
after the household. This may lead the
woman herself to experience mental
health problems such as depression
and anxiety and may only come to the
attention of services during a
pregnancy and childbirth where mental
distress may be picked up in the form
of post natal depression.
In the case of the male partner coming
to the UK, there may be much family
tension between the male and his
wife’s family as he may feel tricked
and betrayed once he realises the
extent to which his wife may be ill.
Due to the perceived stigma and
shame of a failed marriage, the wife’s
family may take over the responsibility
of their daughter’s household including
cooking, care of children and offer
financial assistance to ensure the
marriage is not dissolved once the
husband receives permission to stay
in the UK permanently. This was very
much the case in Sadia’s family as her
mother had pushed for Sadia to be
married to a maternal cousin and felt
it would be further shame for her in
particular if her daughter was divorced.
The conclusions to be drawn from this
are obvious: where an arranged
marriage is to occur between a person
with a diagnosed mental illness from
the UK and a person from Pakistan,
the potential partner from Pakistan
needs to be made fully aware of the
circumstances so that they can make
an informed choice. This is not only
the most ethical position, meaning the
marriage remains arranged rather than
forced, but also avoids much potential
heartache in the future.
Death and bereavement
Death and bereavement are times
when a family is most likely to follow
Islamic teachings whether they are
practicing or not in everyday life;
therefore Islamic practice will be
referred to in this section with any
10
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Sadia
Sadia is a young woman of Pakistani origin who has managed an obsessive
compulsive disorder since her teenage years. Sadia’s family took her to
Pakistan and married her to her cousin Tariq. This has exacerbated Sadia’s
illness to the point that she hasn’t been able to manage her rituals and the
demands of her married life since Tariq came to live with her and her family
in the UK. Tariq is not supportive due to a lack of understanding around
Sadia’s OCD, believing that she is making everything up. Sadia’s family are
fearful of the shame that would come to the family if Tariq left and at times
while working with the family it was felt that Tariq took advantage of this.
Sadia’s family affords Tariq’s living expenses and on one occasion Tariq left
home after an argument involving extended family members on both sides
of the family, insisting on Sadia apologising to his family before returning
home. Sadia described the incident and talked about how degraded she felt
apologising to protect the family’s honour even though she didn’t feel that
she had been in the wrong. Sadia’s Mother performs many of Sadia’s rituals
for her such as doing household chores in the way Sadia feels they should be
done and doing them repeatedly to ‘keep the peace’ in the house.
variations in Pakistani culture being
made explicit. Muslims believe that
death is divinely willed and when it
arrives it should be readily accepted.
With this in mind, there is rarely any
questioning by the bereaved as to
why they have lost their loved one;
therefore it would not be culturally
appropriate to voice such questions
during the mourning period or
afterwards which could cause a barrier
during talking therapies if the topic of
discussion is one’s feelings about
losing someone.
Muslims are always buried and never
cremated and the dying person is
encouraged to recite and declare his
or her faith. Upon death the body is
treated gently and with respect, being
washed or bathed, scented, and
covered with a clean cloth for burial.
It is very important that the body is
released from the hospital, with all the
necessary papers as unnecessary
delays in the burial would cause
distress to the family. Muslims are
directed to conduct the burial as soon
as possible after death. These Islamic
values are strong in Pakistani families
and it is common in Pakistan to bury
the person on the day of their death;
therefore families accustomed to this
practice may find it particularly
distressing in the event of a delay.
While Islamic traditions recommend a
person to be buried in the area they
die, it is usual for a Pakistani person
living in the UK or their family to have
their body flown to Pakistan as their
final resting place. One of the main
reasons cited for this is that Muslims
are required to be buried wrapped in a
large cloth without the wooden coffin
which is not permitted in the UK. It may
also be that people want to be buried
in Pakistan to be buried with other
deceased relatives. The decision to fly
a body to Pakistan for burial can place
undue financial pressure on the family
as it is an expensive process.
When there has been a death in a
household, it is common practice for
friends and relatives to visit from all
over the UK, the family being
supported by local relatives with food
and providing overnight
accommodation where necessary.
Islamic practice recommends mourning
for a period of three days for any friend
or relative, however cultural practices
vary and in some cultures a period of
mourning can be up to forty days. In
the case of a wife losing her husband
the period of mourning lasts for four
months and ten days. This period of
time is referred to as ‘Iddah’ or ‘period
of waiting’ during which the wife is
encouraged to perform only those
duties that are absolutely necessary
and is not allowed to remarry until her
‘iddah’ period is over. There are a
number of reasons for this, amongst
those are giving the wife time to grieve
without the demands of everyday life
and she is not allowed to marry to
prevent confusion of the child’s father
were she to fall pregnant if she
remarried. During the mourning period
weeping or crying quietly is permissible
in Islam, but crying loudly or wailing is
discouraged; however, in some
Pakistani cultures wailing still takes
place, particularly amongst women.
married and have children of their
own, their status changes and they are
thought of as mature. This is not linked
to age as status in this context would
not change until marriage, regardless
of age.
Another phase is when one’s children
are married and they become
grandparents. In some cases this could
be as early as the late thirties when
the individual is seen to have fulfilled
their responsibilities and is elevated
in status to be considered an older
or more respected person. The final
phase is when people become more
religious and spend more time in
worship and resting while the
children and grandchildren look after
their needs.
Points to consider…
As Muslims are taught to accept
the passing of a loved one and
not question it, people may find
it difficult to open up during
talking therapies as they may feel
guilt over their feelings.
Families may travel to Pakistan at
short notice if a relative passes
away there. As these visit can be
arranged in a matter of hours,
families may not be able to
contact practitioners if a service
user is also travelling regarding
medication or other issues
relating to their care whilst away.
Older people
Pakistan is a hierarchical society and
one of the commonalities that runs
across all Pakistani cultures is the
respect of older people because of
their age and position. Older people
are seen as being experienced and wise
and in social settings may be served
first and have drinks poured for them.
It is widely unaccepted for older people
to go into a residential care home as it
is seen as an honour to look after older
members by the young although
homecare is usually accepted.
In decision making, the most senior
person by age or status (this could
include being head of the house or
in a job viewed as respectable) is
expected to make decisions that are
in the best interest of the group.
Points to consider…
Immediate family members may
try to keep the service user’s
illness a secret from other family
members or in laws to prevent
stigma and impact in the
relationship if the spouse is still
in Pakistan. This may add more
pressure on the family and
service user to ‘recover’ so they
can get pregnant in the case of a
female or get a job in the case of
a male to show wider networks
that everything is ok.
Family pressures can exacerbate
a person’s illness more so than in
a person that is not from a
Pakistani background.
If a close family member passes away
in Pakistan, their family in the UK may
wish to go to Pakistan at short notice.
If it is deemed that there would not
be suitable care for a service user
while caregivers are away, the decision
may be made to take them along
without consulting practitioners as
priority would be given to being
united with family in Pakistan during
the time of loss.
Age
In the Pakistani culture, ‘age’ is not just
physical but is also linked to phases in
life. For example people are considered
to be ‘young’ before marriage and
their opinion may not be sought in
family matters; however, once they are
Some older Pakistani people settled
in the UK may choose to spend the
winter months in Pakistan as it is
believed that spending time in a
warm country promotes health
and wellbeing.
Titles
Similar to many other cultures, an
older person will not be referred to
by name as a mark of respect. Older
people will be referred to as uncle,
auntie or as grandparents (in their
respective language) if they are older.
The word ‘ji’ is commonly added to
titles as an added mark of respect,
for example ‘chachaji’ would be a
paternal Uncle (chacha) with ‘ji
added for respect.
Points to consider…
As older family members are so
well supported and cared for
within the family network, a
deterioration in physical health
will be picked up quickly.
Concerns around mental illness
may not be picked up if the
awareness is not there as the
older person will be
accompanied to appointments
and may not access situations
where mental health problems
could come to light such as older
people’s groups.
11
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
Often titles significant in the
community or religious sense may
be used such as ‘Haji’ if someone
has completed the Hajj pilgrimage
or ‘Choudhary’ if someone is a
landowner or in a position of power
in a village setting system; although
Choudhary has more recently been
used as a surname.
Names
Names and their meanings are very
significant in the Pakistani culture. First
names are considered to influence the
individual’s personality and life and
parents or older family members may
rename a child if they develop ongoing
ill health or other problems as the
name may be seen as ‘heavy’ for the
individual; ‘heavy’ in this context
would be if the definition of the name
had a negative connotation such as
‘sacrificer’ or ‘oppressed’ and also if
the name was that of a historical
figure that had lived a difficult or
trying life. Families that are more
culturally driven would usually
subscribe to this notion.
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Points to consider…
Considering the naming
combinations, it is not unusual
for members of the same family
to have different surnames, for
example a father may be called
Mohammed Atif Khan and his
daughter may be called Samina
Bi. Samina would not inherit her
husband’s surname upon
marriage.
Pakistani families and communities
The concept of family
In Pakistani communities the concept
of ‘family’ is the basis of social
structure and individual identity
encompassing more than the nuclear
family and immediate blood relatives.
Family is a term that is used to
describe distant relatives as well as
those acquired through marriage and
includes people from the same
baradari (tribe), friends and
neighbours. Some people may also
refer to people from the same village
or general area in Pakistan as part of
their family. Amongst Pakistani
families, there is a greater sense that
a person does not only represent
themselves but is part of the ‘family’,
therefore successes and failure, praise
and shame can be shared by the family
in the wider sense.
Marriage
Who and how we choose to form
couple relationships with, marry and
have children with has a strong
cultural component. The relative
weighting of determinants such as
practicality or romantic love differs
between cultures, within them over
time and varies between individuals
within that culture.
Traditionally within Pakistani cultures,
marriage is seen not only as the union
of two individuals but is seen as an
alliance between families, or often a
reconfirmation of alliances within the
family in the broader sense outlined
above. Within traditional families,
suitable partners that meet the family’s
expectations around family, tribe,
wealth or education, are suggested to
the individual by a respected member
of the family to seek their opinion on
the match. This process can work in
the reverse order where the individual
(more often the male than female)
suggests a partner to their parents or
other respected member of the family.
Providing the person being suggested
meets with the family’s expectations
and neither of them is already
betrothed, the marriage is usually
arranged in the traditional way.
Arranged marriages often have very
positive outcomes and are not to be
confused with a forced marriage.
12
Sometimes individuals are forced into
a marriage where one or both partners
do not consent. In this case the
individual’s choice is overlooked
because of the perceived benefits of
the match to the wider family such as
reinforcing family ties, culture or for
economic reasons. Such arrangements
can be the cause of much distress
and there are services available to
help people suffering in these
circumstances.
The process of choosing a partner or
having a ‘love’ marriage is becoming
increasingly popular in the less
traditional families living in the larger
cities where dating or marrying
someone outside the ‘family’ is now
also becoming acceptable.
Marriage and mental illness
Where a young family member has a
diagnosis of mental illness a marriage
may be sought as a way of solving the
problem and/or share the burden of
care. This could also be considered
as a social inclusion approach when
mental illness is not seen as an
exclusion from normal life roles such
as being a partner or parent.
Points to consider…
It is not unusual for extended
family members to have input
into matters relating to the
service user.
Sometimes an older child is used
to interpret and talk about
problems. This is seen by the
family as acceptable because an
older child is encouraged to take
on adult duties from a young
age; however, it is important for
practitioners to consider the
child’s wellbeing and use an
interpreter for anything but the
most basic interpreting.
Immediate family members of
the service user can sometimes
feel pressurised by family
members in a position of power
or authority such as a parent,
uncle, aunt or in laws of the
service user. These family
members could live nearby,
elsewhere in the UK or abroad.
Parents may take the decision to find
a partner in Pakistan where a poorer
relative would agree to marry their son
or daughter to enhance the family’s
economic status, particularly with a
son where it is felt that he would be
able to earn money in the UK and
support the family back home. The
family in Pakistan would then rely on
their son once he was in the UK to
provide financial support for their
sibling’s weddings and to provide
electrical goods such as laptops and
televisions in addition to a monthly
allowance. This has been a recurring
theme with families I have worked
with and has been the case for Sadia
and Tariq (see case study page 10).
This arrangement may lead to further
complications once the spouse comes
to the UK and the severity of the illness
is realised by the partner from Pakistan.
Where the woman arrives from
Pakistan, she often has no way
of sharing her experiences of living in
a country where she does not
9
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
to lack of space, a property adjacent to
the family home or nearby will be
purchased to keep extended family as
close as possible. In Pakistan it is still
not widely accepted for a couple to
move out of the husband’s family home
and in such cases this will only happen
where there is a family rift or
diasgreement. The young couple is
almost always seen as being responsible
for the separation, for not showing
tolerance and patience to their elders.
In the UK, many families follow a
similar model. Families in the Central
Ward of Peterborough have preferred
to extend small properties to allow for
growth over moving into larger homes
which would mean moving out of the
area. Extended families living in the
same home or nearby are respected by
other community members as they are
seen to be practising true Pakistani
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values. For this reason, families often
resist the urge to separate after
marriage as they are aware of the
stigma associated with moving away.
Where couples do separate after
marriage, significant time is often
spent at each other’s houses to show
that the family is still a strong unit. This
custom usually only applies to sons as
daughters can be married outside the
area but would have the same
expectations placed on them in their
husband’s home. This has implications
for when clinicans may consider that it
would be benefical for the service
user’s mental health to move to
supported accommodation either to
help their recovery or to manage with
risk issues. Such a move away from the
family home could produce an
additional stigma in addition to that
of mental health, making it an even
harder move to achieve.
Points to consider…
An appointment with a clinician
may not be kept if a family
member or friend arrives at the
house unannounced as it would
be considered rude to ask the
person to return at a different
time.
Families with very traditional
values only plan their calendar for
a number of days, therefore it is
not unusual for an appointment
sent weeks in advance to be
forgotten or to be confused with
a different date. The service user
is not being awkward, they simply
may not be used to this,
particularly if they do not have
school age children to provide
structure to their day or are new
arrivals to the UK.
If embarking on an extended
piece of work with a service user
and/or their family, it may be
useful to emphasise the
importance of keeping
appointments, attending on time
and notifying someone if they
cannot attend.
Pakistani communities in Peterborough
Localities
Maliha
The majority of Pakistani families in
Peterborough are from the Mirpur area
of Azad Kashmir that have been
settled in the UK for over 50 years.
In line with national trends, there are
a significant number of Punjabi
Pakistanis followed by people from
other areas such as Sindh. The
Pakistani community is concentrated
around the Central Ward area
expanding out to surrounding areas
such as West Town, Dogsthorpe, New
England and more recently Netherton,
with a few families living in other areas
across Peterborough.
Travel to and from Pakistan
It is customary for people to keep close
ties with family in Pakistan as well as
family in and around the UK and
annual holidays to Pakistan for periods
of four weeks or more are common to
make the cost of travel worth while.
Popular reasons for travelling to
Pakistan apart from visiting family are
to familiarise children with their culture,
marriage and to promote the traditional
customs and values when living in the
UK. Visits to Pakistan are usually a
highlight for people of Pakistani origin
as they may not have regular holidays
as understood in the UK. Families
spend time shopping for their family in
Pakistan and family members in the UK
tend to visit to say goodbye, making it
a time of happiness and anticipation
and this was the case for Maliha who
benefited immensely from seeing her
family in Pakistan for the first time
without her abusive husband.
Clients from the British Pakistani
community frequently travel to
Pakistan to meet their relatives and
for holidays. These trips to Pakistan
can last for a number of months and
therefore raise the issue of treatment
whilst there. When in Pakistan some
people visit shrines, faith healers and
also see a psychiatrist.
It is prudent to advise clients that whilst
they are in Pakistan they continue with
the medication they are taking and not
change it unless advised to do so by the
UK treating team. This is to prevent
clients from suffering relapse or return
8
Maliha had been diagnosed with depression and had taken medication for
her condition for many years. She came to the attention of secondary care
services upon the birth of her child and separation from her husband which
followed shortly after. Maliha has other children and had endured domestic
and financial abuse from her husband for many years. Although she had
been visiting doctors for a long time, Maliha’s husband had been allowed to
interpret for her and she was never seen alone to have the opportunity to
share her ordeal with anyone. Maliha’s eldest daughter was still under 16 but
not in any form of education or training and took on most of the household
chores and looking after her younger brothers and sisters.
I found Maliha very low, isolated and scared of telling anyone about her
problems, spending most of her time feeling very tired and down. Maliha
said she found it difficult to undertake any household chores as her body
ached afterwards. I interpreted some basic information about depression to
her in Punjabi and worked in a pictorial way to help her understand her
depression and how the mental state was linked to her physical state
resulting in the pains and aches. Maliha improved over the coming weeks as
she was able to talk about the issues around her marriage in a cultural
context. During a review, we found a number of things that had been
misinterpreted such as Maliha hearing water when she had actually been
describing her depression and how she felt that she was drowning in her
sadness. Maliha responded very well to the basic techniques around
managing her depression and within a few months was able to take over
many of the household chores from her daughter and went to visit her
family in Pakistan and was subsequently discharged.
of their illness which would spoil the
time they are in Pakistan. It is worth
noting that there are differences in
practices, medications available and
doses of drugs. It also might not be
possible to continue the medication
started in Pakistan.
Pakistan also has a high rate of
Hepatitis and other water and blood
borne infections. Caution is required
with those medications that are
administered by injection e.g. Depot.
Service users and their families should
be advised to buy needles from
reputable sources and to dispose of
them safely.
For clients who are on medication that
requires blood tests it is important to
consider the following: The blood tests
may not always be reliable, depending
on the type of health care facility in
which they are taken. There are issues
with used needles being repackaged,
so appropriate care should be taken
in sourcing clean ones. People taking
Clozapine will need to register with
the Clozapine monitoring service in
13
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
Pakistan. Clozapine is not a commonly
prescribed medication in Pakistan and
the monitoring procedure differs to
that in the UK. The user will need to
obtain for themselves a blood test at a
hospital or private laboratory for a full
blood count. They or a family member
or carer then phone the drug
company's monitoring service and
inform them of the results. The drug
company will then deliver to where
they are staying and will ask to see the
results printout in confirmation before
handing over the medication.
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Points to consider…
Not all people with a Pakistani background will have a good practical
knowledge of Urdu, therefore it is important to ascertain the particular
Pakistani language or dialect the service user speaks at home.
Mirpuri and Punjabi are the most popular Pakistani languages in
Peterborough. Both languages use the written form of Urdu as there is no
written form of Mirpuri and Pakistani Punjabi speakers will not be able to
read or write the written form of Punjabi.
Most interpreters that speak a Pakistani language will also speak Urdu.
Service users may wish to have a same sex interpreter.
Pakistani languages & interpreting
The term ‘Pakistani’ includes a mosaic
of different cultures. The national
language is Urdu and is spoken in the
public sector as well as English. Many
other languages are spoken in the
different regions of Pakistan such as
Punjabi, Siraiki, Sindhi, Pashtu, Balochi,
Hindko and Gujurati and the diversity
in languages is often reflected in
differences in culture, diet and
traditions. It would be true to say that
a significant number of people living in
more isolated or rural areas of Pakistan
may not speak Urdu.
The majority of Pakistani families settled
in Peterborough speak Mirpuri or
Punjabi. This is an important point to
keep in mind as not all those that speak
Where the service user is unable to read or write, they can be involved in
using pictures and photos from South Asian media to tell their story.
Examples of alternative media include the Asian Bridal magazine, MAG
the weekly and the Jung, Nation & Watan newspapers as well as
mainstream media.
Mirpuri or Punjabi will be comfortable
with having an Urdu interpreter even
though Urdu is the official language of
Pakistan. It may be more appropriate to
request an interpreter that specifically
speaks Mirpuri or Punjabi, as many
interpreters registered to speak
languages from Pakistan will almost
always have a good knowledge of
Urdu. Mirpuri and Pakistani Punjabi
speakers will use the written form of
Urdu if they need to write something
down in their language.
Weight gain or loss in adults is viewed
in a similar way.
More full bodied actors and actresses
are common in the Pakistani film
industry and weight loss, even when
done in a healthy way is sometimes
viewed as a sign that something is
wrong physically in the form of an
illness or due to mental distress such
as problems in the family; although
younger people may identify more
with the ‘Western’ ideals regarding
weight and may therefore be more
aware and conscious of gaining
weight. In Parveen’s case the family
were concerned that the extended
family or community members would
think there was something wrong in
the family and that was the reason for
Parveen’s weight loss, and her lack of
eating was a cause for tension during
festivals such as Eid.
In many Asian cultures including
Pakistani cultures, foods are
considered in terms of ‘hot’ and ‘cold’.
This is not concerned with the
temperature at which the food is
served but rather the ‘effect’ on the
body, which can be harmful if food
combinations are not balanced. For
example, almond nuts are ‘hot’ when
eaten as a nut but ‘cold’ if soaked
overnight in water providing the outer
layer is removed. Mangoes are
considered ‘hot’ and should be
consumed with yoghurt milk (lassi) as
this has a cooling effect on the body
therefore neutralising the heat in the
mangoes. Although not so prevalent
in Pakistani communities, Hindu
communities associate certain foods
with mental and emotional states such
as meat with aggressive behaviour, as
well as recognising the physical ‘hot’
and ‘cold’ effects on the body.
The sense of time
‘I remember visiting my
great grandmother’s house
in Pakistan as a child and
not having a clock in the
house, even if there was it
would have been no good
to her as she couldn’t tell
the time.’
14
How time is understood and valued
differs between cultures. This is an
area that industrial businesses have
had to pay close attention to in order
to function efficiently in different
countries. Some cultures value
punctuality, meticulous planning and
stay committed to them. Countries
that typify this approach, technically
known as ‘monochronic’ are the USA
and Germany . In contrast there are
polychronic cultures which include
Pakistan. In these countries multiple
activities occur at once, there is greater
flexibility around time with the focus
on the relationship being more
important than promptness or the job
in hand.
Timing is very relaxed in Pakistan,
particularly in the more rural areas
away from office based companies.
Social visits to family and friends are
made unannounced as many
households have an ‘open door’ policy
where the door is left unlocked during
the day for people to visit. The main
structure to the day is around the five
daily prayers and timings may be given
around these, for example, ‘I’ll see
you after dhuhr’ or ‘make sure its
before maghrib’.
Points to consider…
Psycho-education is key when
working with Pakistani families
around eating disorders to help
them to understand the
condition and support the
recovery of the individual.
Talking therapies around eating
disorders often involve individual
and family work. Families may not
be comfortable with talking
about the family and its dynamics
as this would normally be done
on a one to one basis or with a
small trusted same sex group.
Families will most likely feel under
pressure from the wider
community and may hide the
problem rather than talk about
it openly.
Weddings and such functions are very
relaxed affairs with no set start time
and guests arriving and being served
at various times. Although the
structure of the day is relaxed, there
are customs around visiting a family
where there has been a birth of a
child or a death as soon as possible
and offence could be taken if a family
member or friend were not to visit on
such an occasion. Similar rules apply
to inviting a newly married couple
around for a meal after their wedding,
as the first few months are usually
taken up by being invited by family
and friends to meals where delicacies
are served and gifts given to the new
bride and groom.
Accommodation
It is customary in Pakistan to buy and
acquire land so that property can be
built and extended as the family size
grows. Often, a house will start off
with two or three rooms and will then
be extended as per the family’s needs
which is particularly the case in more
rural areas. In more suburban areas
where it is not possible to extend due
7
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
increase in women choosing to wear
the ‘hijaab’ which is an opaque piece
of material wrapped around the head
and held secure with a pin. This can be
worn with shalwar kameez, ‘Western’
clothes or then with a jilbaab which is
a long coat like dress that reaches
down to the ankles. Pakistani dress is
linked to modesty which is a value of
Islam and is usually maintained by
people of Pakistani origin however
they may choose to dress.
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Parveen
Parveen is in her teenage years and has been diagnosed with anorexia.
The immediate and extended family’s diet consists mainly of Pakistani food,
particularly those that are rich in spices, flavours and cholesterol and the
family equate being ‘big’ with being healthy and well. The women of the
house insist on cooking and serving food to Staff whenever they visit, this
being seen as a sign of hospitality and graciousness. This includes being
served fried food with fizzy drinks early in the morning and three course
meals when visiting to support Parveen to eat during lunch visits. The
family often insist that everything on the table be sampled including large
quantities of fried food.
Gold jewellery
Pakistani communities will have
differing views about men wearing
gold jewellery as some men may wear
a gold ring, bracelet or chain and
others believe it is not permitted in
Islam. Women however are
encouraged to possess and wear gold
jewellery as a sign of wealth and good
status. It is traditional for women to
wear gold bangles and other jewellery
on a daily basis and daughters will be
given gold jewellery by direct family
members upon their marriage which
stems from the notion of giving
something that can be used during
times of hardship. Often gold jewellery
is passed down to daughters and
daughters-in-law.
Diet and food
One of the most common markers of
cultural identity is the individual cuisine
that a culture has developed. This is
one of the most accessible ways that
a person from one culture can
experience and value that of another.
Pakistani food fits within the wider
culinary framework of Indian food
and as such is something that has
familiarity and value in the UK.
Food is an industry that excels in
Pakistan even when the economy is
down, perhaps because this is one
of the few areas where people from
lower socio economic groups can
demonstrate control and discretion,
as affording a car or going on a lavish
holiday would not be achievable.
6
Parveen’s family were encouraged by her dietician in supporting her to
stick to a food plan that would slowly introduce eating back into her daily
routine again. The family continued to offer Parveen other foods at the
dinner table despite being explained that this would hinder her progress.
The family have different ideas about the ‘truth’ regarding diet that was
not shared with Parveen’s clinicians; and seemed to attempt to introduce
extra foods to Parveen whenever the opportunity presented itself. This
hindered Parveen’s progress and she often spoke about an atmosphere in
the family home in which they did not speak openly about problems and
issues and how difficult it was for her to share things that were on her
mind with her mother or other family members. After months of support,
Parveen’s family are now taking part in family therapy with a view to
admitting her into hospital if her weight does not improve.
Pakistani food is rich in flavour, spices
and high in cholestrol with sweet
desserts containing a high sugar
content. The use of meat and chicken
is very common at mealtimes and it
would be considered offensive to
serve a completely vegetarian meal at
a dinner party or to guests, although
a vegetarian accompaniment would
be acceptable.
Culturally, food is linked to hospitality,
seen as a sign of good living and the
sharing of food as an act of kindness.
It is common to serve food at festivals
and gatherings and is given away to
the poor during times of happiness
such as a wedding or the birth of a
child or grandchild.
Guests will be encouraged to share a
meal and may have food put on their
plate and offered seconds or thirds
despite the recipient’s protest, as
illustrated in Parveen’s case. Babies and
children are seen as healthy if they are
on the upper end of the normal
weight range and may often receive
comments about their health
depending on how much weight they
have gained or lost, which is in
contrast to the ‘Western’ culture
where it may seem inapproriate to
comment on a baby or child’s weight.
Mental health and Pakistani communities
Spirituality and understanding of mental illness in Pakistani communities
Excerpt from ‘Psychiatric Health Laws in
Pakistan: From Lunacy to Mental Health
By Ahmed Ijaz Gilani
There are many players and factors involved in the access, provision,
delivery, functioning, and uptake of mental health services in Pakistan.
Awareness about mental illness is still poor in Pakistan. Such illness is
generally attributed to supernatural causes—it is considered to be a curse,
a spell, or a test from God.
Those who experience mental illness often turn first to religious healers,
rather than mental health professionals, since patients and their families
tend to have great faith in these healers. Religious healers use verses from
the Qur’an to treat patients. Next, patients turn to traditional and
alternative healers, who are also popular in Pakistani society.
Help from the mainstream health-care system is usually sought late in the
course of the illness; however, the referral system is inefficient and,
particularly in the case of individuals who are mentally ill, patients are usually
taken by their families directly to tertiary or specialist hospitals, rather than to
primary-care practitioners. It is, however, important to note that many
mental illnesses can be treated and managed by primary-care practitioners.
The private sector also plays a major role in providing psychiatric care. For
those who can afford it, private psychiatric care is an option frequently used.
[Excerpt from section on Mental Health Infrastructure].
In view of the above account of
mental health services in Pakistan,
understanding of mental illness in
Pakistani communities is significantly
different from the models commonly
used in the UK. As well as mental
illness being considered in a holistic
context including environment and
physical health, it is also understood
in the context of spirituality.
Belief in supernatural forces is
prevalent in Pakistan. Jinn (anglicised
to genies), evil eye and spells are part
of daily life in Pakistan and spiritual
healers can be found in most markets
and street corners.
According to Islamic belief, jinn are real
creatures that form a world other than
that of mankind. There is little detailed
description of jinn in the Qur'anic and
Prophetic literature. The term ‘jinn’ is
derived from Arabic ijtinan, which
means 'to be concealed from sight'.
Although they reside in what are in
essence parallel worlds, humans and
jinn are believed by Muslims, to have
some ability to influence each other
towards both positive and negative
ends. Satan (who is within the Islamic
tradition a jinn and not an angel, and
hence has the choice to disobey) is the
most infamous of the jinn and is
primarily concerned with enticing
humanity to forget its divine origin.
According to Islamic writings, jinn live
alongside other creatures but form a
world other than that of mankind.
Though they see us they cannot be
seen. Characteristics they share with
human beings are intellect and
freedom to choose between right and
wrong and between good and bad,
but according to the Qur'an their
origin is different from that of man.
According to Islamic scholars, a person
unable to think or speak from their
own will, experiencing seizures and
speaking in an incomprehensible
language may be possessed by jinn;
however, more often than not a
physical cause can be found for the
unexpected behaviour and many
15
NHS Working with Pakistani Service Users 2011 PP.qxd:A4
spiritual healers will encourage families
to think about the possibility of a
mental illness where they feel that their
full criteria for possession is not met.
The role of the Islamic therapist in cases
of possession, who must have strong
faith in Allah, is to expel the jinn. This
is usually done in one of three ways –
remembrance of God and recitation of
the Qur'an (dhikr); blowing into the
person's mouth, cursing and
commanding the jinn to leave; and
seeking refuge with Allah by calling
upon Allah, remembering him, and
addressing his creatures (ruqyah). Some
faith healers strike the possessed
person, claiming that it is the jinn that
suffers the pain. The practice of striking
the person is deplored by Muslim
scholars as being far from the principles
of Islam. The general approach of
expelling evil spirits by convincing them
to leave is similar to the passage in the
New Testament (Luke 8:24) where Jesus
expels demons from a man who is
possessed. Though it is not often
spoken about publicly the Church of
England and the Catholic Church retain
Ministries of Deliverance for exorcisms.
Within mental health services over the
last twenty years there has been a
growing awareness of the spiritual
component to the mental illness with
the development of organisations such
as the Spiritual Crisis Network.
Although the individual or their family
may believe there to be a spiritual
component to a condition, this does
not always mean they believe the
individual is possessed by a jinn. A
belief in spells and evil eyes could mean
that a mental as well as physical illness
is viewed as having a spiritual element
to it other than possession therefore it
is important to engage with the
individual and their family to ascertain
their views on the condition and its
causes as this often proves instrumental
to recovery.
Through working with families that
believed there to be a spiritual
component to the service user’s mental
health, it has been important not limit
ourselves to medical treatment, and to
consider the wider options of
psychological therapies as well as
family work with those closest to the
service user.
The differences of cross cultural
understandings of mental health can
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be appreciated within the context of
models of how beliefs in Asia are
different from the ‘Western’ views
such as those illustrated in the table
below which has been developed
from an article by Hilty on cultural
differences:
Pakistani culture and communities
Islamic influence and culture
Asian
Western
Core values of ancient China such as
hierarchy, moral development,
achievement and social responsibility
as well as a dualistic model medical
system based on principles of balance
and harmony.
Pathology driven, overlaid by the
values of ancient Greece such as
individuation, self control and self
efficacy.
Cognition is abstract, paradoxical,
circular and indirect. The universe is
seen as a web of infinite connections
(holistic cognition).
Cognitive process is one of logic,
critical analysis and direct and rational
thought in which the universe is
conceptualised as the sum of its parts
(analytic cognition).
Socio-centric model of self which is
formed within the social context and
defined by it at any given moment. A
sense of self requires emotional
connectedness.
Ego-centric model of self where each
person’s sense of self is considered
autonomous and unique, individuated
and largely consistent regardless of
context.
Orientation is one of interactionism,
in which the presence of complex
causalities is assumed and the focus is
on relationships and reactions
between persons or the person and
the surrounding environment.
Orientation of the individual is one of
dispositionism, in which the internal
disposition of the individual is the
primary consideration.
Health is inclusive of all aspects –
physical, mental, emotional, spiritual
and social, conceived of as a state of
harmony and balance, illness being
termed as ‘patterns of disharmony’.
The model of Cartesian duality of
mind and body is adopted where the
two are separated, hence mental
illness being treated in many areas
independently of physical and spiritual
symptoms.
Religious beliefs and values have a
strong influence on society and its
culture. Even a person of longstanding English heritage who is an
atheist is likely still to hold beliefs and
attitudes that are Christian in origin
as a consequnce of growing up in a
society with a substantial Christian
faith history.
In this context it can be difficult to ask
a person to focus on themselves as an
individual during cognitive behavioural
and solution focused therapy , as they
may consider this a selfish act or may
simply not be accustomed to thinking
of themselves as an individual entity.
This echoes some African cultures
where one is seen to exist through
others in their family and community.
Often blood ties are seen as more
important than money therefore it
may not be unusual for a parent to
control their children’s finances until
they are married and sometimes even
after marriage. On the surface this
may be seen as a selfish act but
parents may put all the money they
collect from their children in a joint
Islam is the main religion practised
in Pakistan with around 97% of the
population being Muslim and the
remaining 3% made up of Christian,
Hindu and Sikh communities. Although
Shari’ah (Islamic law & jurisprudence) is
not strictly practised in Pakistan, Islam
governs people’s personal, political,
economic and legal lives on a daily
basis making religion an important
factor to consider when working with
Pakistani families, as the lines between
faith and culture are often blurred.
Pakistan and Azad Kashmir
Pakistani culture is made up of a
mosaic of Islamic traditions and is
influenced by Hindu culture, which is
evident in the way weddings are
celebrated and events such as ‘Basant’
(spring festival). Pakistani Muslim
families or individuals within them can
be either culturally or Islamically driven
and still identify themselves as
Pakistani and Muslim. Variations can
include naming traditions where a
family driven by culture may choose an
Urdu name such as Shabnam (morning
dew) for a female child and Sahil
(seashore) for a male child. A family
with a more Islamic outlook may give
their child an Islamic name such as
Maryam (Mary) for a female child or
Muhammed for a male child although
cultural and religious names may be
given together. Social areas such as
the level of free mixing may also differ
depending on whether a family is
more cultural or religious as well as
the level of access to media in the
home such as Hindi film and television.
As Mirpur has no airport, passengers
from the UK will often use Pakistan’s
Islamabad airport from which Mirpur
is a 2 to 3 hour journey.
Unlike Christian families where the
gap between practising and non
practitising Christians is much wider,
the majority of Muslim Pakistani
families identify quite strongly with
their faith and will practice it at some
level. As a minimum, families may
16
have a pork and alcohol free diet and
pray or read the Holy Qur’an
occasionally whereas a practising
family will adhere to the five daily
prayers, observe hijaab (Islamic dress)
and may not allow free mixing. Adding
to this an influence of the Hindu and
British culture in Pakistani families
highlights the level of diversity that
makes up ‘Pakistanis’ and people from
a Pakistani background.
Azad Kashmir is a self governing state
to the North-East of Pakistan which
is administered by the Pakistani
Government. The largest City in Azad
Kashmir is Mirpur which is
neighboured by the province of Punjab
in Pakistan. The largest Pakistani
community in Peterborough is the
Mirpuri community coming from
Mirpur and the surrounding areas,
followed by the Punjabi community.
Pakistani dress
When we first meet a person we will
be making rapid judgements of who
they are and where they fit in to our
understanding of society. In this rapid
account the clothing a person is
wearing can play an important role.
The clothes that we wear can be a
strong marker of personal identity,
age, class and culture.
Points to consider…
Where possible, allow the service
user to describe in their own
words how they view their
cultural identity.
This is important considering the
cultural diversity of Pakistani
families depending on how
‘traditional’ or ‘Western’ they are,
how much they are influenced by
practices deriving from the Hindu
culture and how closely they
practice the Islamic faith.
Gaining this information will help
you to recognise the level of
importance the individual’s
cultural heritage holds for them
and how this may influence their
treatment and recovery.
Point to consider…
Some people from Azad Kashmir
may identify themselves as
‘Pakistani’ on ethnic monitoring
forms but will consider
themselves as ‘Kashmiri’ or from
‘Azad Kashmir’ in everyday
conversation.
The national dress of Pakistan is
shalwar kameez which is a long top
with loose, baggy trousers. Men may
also wear a skullcap and women will
usually wear a large scarf with their
shalwar kameez.
In the UK, men often adapt to the
‘Western’ style of dress unless they
come to the UK when they are older,
where the preference is to wear
shalwar kameez. Women will wear
a variety of dress ranging from the
shalwar kameez worn in the traditional
way or ‘anglicised’ by wearing trousers
with a long top, to totally ‘Western’
dress. In recent years there has been an
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NHS Working with Pakistani Service Users 2011 PP.qxd:A4
in Punjabi and the surrounding dialects
of the area and work with local
families where practitioners felt that
additional support with language and
culture would be beneficial for the
service users and their families. The
cases have been included to illustrate
the points being made rather than as a
measure of success, which varied from
the service user being discharged with
very positive results to very little
change in condition.
Shama Kanwa
Additional comments from the
second author
This has been a hugely rewarding
project to be involved in that is largely
the work of Shama. Working with
clients and families from the Pakistani
community has raised my curiosity
about their culture at both a personal
and professional level. Being culturally
blind, though not as bad as racism is
still not good, it is akin to neglect
compared to racism being abuse. The
importance of cultural awareness is
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two fold. First, it enables a better
understanding and formulation of the
person's psychological distress and
confusion together with its impact on
family and carers. Secondly, it increases
the likelihood that interventions
offered will be successful as they are
taking account of the cultural factors
for and against change.
In working with clients from the
Pakistani community, including people
born in England, it has struck me how
their understanding of mental illness
has greater components of the role
of the body and the spirit in these
conditions, but a lesser appreciation
of the mind, than when working with
clients of long standing English
heritage; a challenge for anyone
wanting to carry out standard
Cognitive Behavioural Therapy. This
has confirmed my bias to suggest
that a holistic approach that takes
account of mind, body and spirit is
usually the best.
Points to consider…
The first and most important
step is to ellicit, in an open and
non-judgmental way, the service
user (and if appropriate the
family’s) ideas, concerns and
expectations.
The second step is to recognise
that symptoms attributed to
possession by jinn are commonly
manifestations of a mental
disorder that will most likely
benefit from medical treatment.
The third step is to appreciate
that, although the patient and
relatives may obviously have
interpreted symptoms incorrectly,
beliefs that are strongly held (and
often socially convenient due to
perceived stigma) will be difficult
to alter at a time when anxieties
are running high.
Stuart Whomsley
‘pot’ out of which they would pay for
their wedding. Sometimes the money
may be used as a deposit for a house
which may be rented out to generate
more income for the extended family.
What should clinicians do when a
patient or the family or friends believe
that jinn are the cause of symptoms
or unusual behaviour?
In such cases where patients are
deemed to have a medical, psychiatric
or psychological disorder but are not
receptive to medical explanations,
patients can be encouraged to 'hedge
their bets’ by taking the prescribed
treatment while continuing with
spiritual therapy. This double strategy
may be the best hope of securing
adherence to prescribed treatments.
There may also be the additional very
important benefit that patients and
their families are willing to enter into
discussion about the other therapies
that are being tried. Whilst these
usually consist of repeated readings
of certain sacred texts, the concern
is that in desperation some families
may turn to exorcists who inflict
physical harm in an attempt to free
the individual from possession –
sometimes with catastrophic
consequences.
4
It is very important, therefore, to
establish channels of communications
with the patient, the family and any
spiritual practitioner whose help is
being sought.
Wider issues around accessing
services
According to a Rethink project focusing
on the Pakistani community’s view on
mental health and mental health
services in Birmingham, successive
studies have shown that people from
BME groups experience relatively
higher levels of mental illness than the
white British population. Some of this
may be attributed to socio economic
factors such as the experience of
racism, unemployment, homelessness,
social exclusion, poor physical health
and living in deprived areas.
Other findings of the research found
that stigma of mental illness needs to
be overcome to enable mental health
as an issue to be accepted and openly
talked about. People may be ignorant
or unaware of the facts of mental
illness and communities may not know
which services are available to them or
how to access these services once they
decide to recognise and ‘face the
problem’. It was also found that
cultural and language barriers can
hinder people from taking up services
and there is a ‘keep it to yourself’
approach adopted across the
community where mental health issues
are concerned.
As the service user will be thinking in
holistic terms, including faith, somatic
symptoms and perhaps mental illness
as understood by ‘Western’
practitioners, it is important for
practitioners to take a similar approach
and elicit an open response about how
the service user and/or their family
views the situation, even if only clinical
treatments are available. This will
enable the practitioner to learn about
any alternative treatments being
accessed such as spiritual healers.
Culture, faith, eastern, western –
ultimately these are labels we attach to
each other to help us make sense of
something that is new or different, the
real success when working with
people is if we can understand what
the labels mean to the individual and
how they interpret their own identity,
only then can we truly deliver a service
that focuses on and responds to the
needs of the whole person.
Conclusion
As discussed during the introduction,
the aim of this document is to
highlight important parts of the
Pakistani culture that will assist
practitioners in working with service
users and their families from Pakistani
backgrounds. We have used our
experiences of working with families
to highlight the issues raised, and the
subsequent input that was given to
support the delivery of a service that
was appropriate. In addition, some
cultural values have been explained
such as attitude towards relationships,
timings and diet that may also assist
practitioners to gain a better
understanding of some of the factors
that may be driving a particular
attitude or behaviour.
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References
Hilty, A. 2010. Western Psychology,
Eastern Cultures – Mismatch? Ezine
articles. Available at:
http://ezinearticles.com/?WesternPsychology,-Eastern-Cultures---Mismat
ch?&id=4130088.
[Accessed 21 November, 2010].
Gilani, A. I, Gilani, U.I, Kasi, P.M,
Khan, M.M, 2005. Psychiatric Health
Laws in Pakistan: From Lunacy to
Mental Health. PLOS medicine, Public
Library of Science. Available at
http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC1215469/.
[Accessed 29 November, 2010].
Introduction
Aap ki Awaz. Our Voice: The
Pakistani community’s views on mental
health and mental health services in
Birmingham, 2007. Published by
Rethink. Available at:
www.mentalhealthshop.org/products/
rethink_publications/our_voice.html.
[Accessed on 29 November, 2010].
Sajid, A. 2003. Death & Bereavement
in Islam. The Muslim Council for
Religious & Racial Harmony. Available
at:
www.mcb.org.uk/downloads/DeathBereavement.pdf.
[Accessed on 3 March 2011].
Culture is a shared, learned, symbolic system of values,
beliefs and attitudes that shapes and influences
perception and behaviour; an abstract mental ‘blueprint’
or ‘code’ and must be studied ‘indirectly’ by studying
behaviour, customs, material culture (artefacts, tools,
technology), language, etc.
Professor Kathleen Dahl
How do you capture ‘culture’ accurately
when it involves people’s visible and
invisible values and beliefs? Is it possible
to be completely impartial when writing
about your own cultural background as
I am doing? Do the experiences I’m
sharing in this work truly represent the
Pakistani culture? Furthermore, is it
‘fair’ or ‘ok’ to produce guidance on
the culture of a whole nation,
particularly one that is as rich and
diverse as the Pakistani culture?
These questions were considered when
deciding to produce this guidance and
weighed against the need to raise
awareness amongst practitioners of
how a service user’s culture may
impact on their engagement with
services and their subsequent recovery.
Pakistan is made up of different states
that vary significantly in language,
dress and ‘culture’, and it would take
a very detailed piece of work to fully
capture the customs of all the states
comprehensively. Considering the
background of the Pakistani
communities settled in Peterborough,
which reflects the cases used in this
work as reference, it seems more
realistic and reasonable to say that
this guidance has been produced on
the Pakistani culture but with ‘a
particular focus on the Mirpuri and
Punjabi communities’, which are the
majority Pakistani communities settled
in Peterborough.
It is almost impossible to measure the
external input people have during their
lives that shapes their sense of identity,
and to pinpoint the extent to which
someone lives their life according to
values passed down through culture
and the impact of their current
environment on them, if that is
1
18
different from when they were
growing up; as in the example of a
person coming to live in the UK as
an adult. As demonstrated by this
point, it is risky to make generalised
assumptions about culture, as cultural
values may be enforced by families
and communities but interpreted by
individuals. It is also important to note
that there may be cultural differences
across generations as there may be a
parent or grandparent that came to
live in the UK as an adult and their
children and grandchildren may be
born and brought up in the UK,
therefore their experiences would be
very different from each other. An
example is where taking the children
to the cinema may be seen as
appropriate by young parents of
Pakistani origin but may be frowned
upon by older members of the family.
For the reasons mentioned above, this
guidance should not be used as an
authority on all things Pakistani but as
a tool that can assist practitioners
when working with individuals and
their families in the context of having
positive regard to the person’s cultural
values and beliefs to build relationships
and aid recovery. The individual and
family should be given the opportunity
to express in their own words what
their cultural and religious1 identity
means to them as it will be unique for
each person.
The small sample of anonymised cases
used in this guidance resulted from
family work that I have undertaken in
my capacity as Community
Development Worker for BMER
communities. I was able to engage
more freely with families as my own
background is Punjabi and I am fluent
Although culture and religion are different things, people may talk about them as one or use the terms interchangeably.
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Acknowledgements
The authors would like to thank the following people for their assistance in producing this document:
Martin Liebenberg for his support in developing the document’s content and direction.
Dr Asif Zia for his contribution to the section on service users travelling to Pakistan.
Professor Zenobia Nadirshaw for reviewing a draft of this document and offering supportive comments.
Ahmed Ijaz Gilani for allowing us to use his article.
Janice Hartley for her advice on spirituality and mental health.
About the authors
Shama Kanwar has worked in community relations for over 14 years both at a strategic level advising Senior
Management on community and equality issues and at grassroots level with specific hard to reach BMER groups. Shama
has worked nationally as an independent facilitator in an initiative involving Police Officers and Muslim communities on
community cohesion and has been instrumental in setting up BME Staff Support networks in three organisations. Shama is
currently working as a Community Development Worker based in Peterborough working with Black Minority Ethnic and
Refugee communities, running community based projects that raise awareness of mental health and how to access
services. Shama also works at length with healthcare practitioners to engage with service users and their families to gain
an understanding of the role culture plays in the treatment and recovery of the individual.
Dr Stuart Whomsley is a clinical psychologist who works in an Assertive Outreach Team. In this role he has a long
established working relationship with a number of clients from the Pakistani community. He is involved in both
community development initiatives locally and good practice guidance for his profession nationally.
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Working with Pakistani service
users and their families
A practitioner’s guide
Shama Kanwar
Stuart Whomsley
HQ Elizabeth House, Fulbourn Hospital, Cambridge CB21 5EF.
T 01223 726789 F 01480 398501
www.cpft.nhs.uk
A member of Cambridge University Health Partners